Certification and Licensure

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What exactly is the relationship between certification and quality of services provided? The trainer I know who has produced the poorest results–in some cases quite negative results–is licensed and fully BCIA certified. Another, who has brought a great deal of positive word-of-mouth awareness to the field–the kind that is best, because it is from satisfied customer to potential customer–is neither. I’ve had BCIA-certified folks in my workshops who had gone through the process with little if any experience and hadn’t the slightest idea what they were doing with clients.

Certification not Needed

First, can you provide brain training service based on knowledge and experience without a clinical degree and/or BCIA certification? My answer to that would be that anyone who has watched with an open mind could not help but notice that some of the best trainers aren’t clinicians, and some of the worst trainers are. We have poor benighted souls on this list who foolishly went ahead and trained family members, neighbors, friends and themselves with designated problems ranging from agoraphobia to bipolar disorder to autistic spectrum to closed head injuries and even psychoses. In most cases these dangerous people were taking over after having spent thousands of dollars with (often BCIA-certified) clinicians who had either had no effect at all or had actually made the client worse. In most cases they did what the “experts” they had paid did not: they gathered information about the brain and determined how to train based on that rather than on some philosophy or recipe book. The cases I’m thinking of are all ones where the “lay” trainer got results–good results–AFTER they were told that nothing more could be done by the experts.

Certification is a Ticket

Some people are willing to pay the money, jump through the hoops, and get it. Others choose not to do so–even licensed clinicians with years of experience and excellent results. The two best trainers with whom I have worked were neither BCIA certified, nor were they eligible. One, an experienced classroom teacher, with remarkable ability to motivate children and their parents, couldn’t even apply for BCIA, since she didn’t have a clinical degree–but she was fantastic! If you really look at the evidence, the whole BCIA premise is that only people with clinical licenses should be allowed to guide clients to help themselves. Not surprising, since BCIA was set up by…people with clinical licenses. It does have the potential effect of keeping the field small and contained within a specific “in-group”, which may well be as much about economics as it is about quality.

I doubt there’s a person in the field who would disagree that over-promising, using the medical language for what is essentially a self-regulation process–the exact opposite of what western medicine stands for–and working with things you absolutely don’t understand are all bad for clients and bad for the fields. To assume that non-clinicians do that–and that no clinicians do –or that non BCIA certified people are more likely to do them than BCIA certified simply doesn’t follow. It’s not unlike the equipment manufacturers who know that battery-powered NF equipment is exempt from FDA registration, who choose to spend the significant time and money to get a piece of paper saying that their equipment is like others already in the field–and then blazon their FDA-approved tag all over their marketing material as if that somehow makes their product better or safer or more clinically effective.

If you use terminology like “treating patients” and use the diagnostic terms, etc., then you might have a problem if anyone complains–and sometimes even if no-one does–because you could be construed to be “practicing medicine (or psychology) without a license.” I don’t believe the fact that you are charging or not has much to do with that. There is no licensure or certification requirement that I’m aware of to provide NF services, but you are much safer–probably even when you DO have your license–if you use a coaching model instead of a pathology model.

The key, for me, has always been to stay away from diagnostic terminology, which is not so easy these days, now that the mental health establishment has arrogated half the language to its own purposes. Used to be someone could say, “I’m anxious” without risking stepping on the toes of some DSM-V guy who threatens that he or she is practicing psychology without a license. As others have said, if we focus on the desired behavioral changes and we look for the underlying brain activation issues, we can often help a person change their own life without slapping labels onto their school and medical and insurance records.

If you say that you are using NF to help clients learn to improve their level of well-being or to pay attention more effectively, without the jargon and diagnostic approach, then you are probably pretty safe from being attacked by other professionals, which sadly is the MUCH greater legal risk in our field that any action by a client! To the best of my knowledge, no-one has ever been sued by a client in the history of NF (though I’m aware of some cases where I might have done so if I’d been the client). All of the legal actions of which I’m aware were brought by a small group of psychologists against other professionals who weren’t psychologists–and all of those were won by those being sued.

There are people on this list to whom I would happily refer a family member for training, many of them clinicians, many not. There are people in the field to whom I would not send a client who lived next door to them. Again, many are clinicians and many are not. As to BCIA, the concept buried in their most basic assumptions that only clinicians should do NF is ridiculous. What prepares a psychologist or therapist to understand digital filters, brain activation patterns, etc.? How in heavens name can we say that a special education teacher can NEVER be qualified as a provider while a dental technician can? Take a good look at the members of the body who set up BCIA’s standards, and you’ll see how remarkable self-serving the organization was–maybe still is.

Economics and Certification/Licensure

Someone asked why other fields mentioned have licensure and certification. The issue is to a very large extent an economic one. By limiting access to the field to only those who come through a specific gate (e.g. BCIA) we can control the number of trainers and keep prices high. Anyone who has ever been treated by a bad physician or dentist or psychotherapist who is fully licensed–maybe even board certified–knows that, as others have said, there are no guarantees.

There are certainly people in the field (I usually assume they are not very busy or successful) who are desperately threatening and pushing to limit trainers. But as of now, if you can find people who want to pay you to work with them or their families, you are welcome to train. Hopefully this will continue to be true in the future, and people who have started enthusiastically by training their own brains, by getting support and training, and who are getting results will always be able to help those who need help without spending the money to get a clinical degree or go through all the BCIA hoops.

BCIA Certification

We’re starting to see in Brazil courses offered to start people down the road to BCIA certification, and at the request of some folks here for advice on whether it was worth pursuing or not, I discovered some interesting information I thought worth passing on.

First, the assumption that many people make entering the field is that you need BCIA to see clients or to compete. If you hang around iSNR or AAPB or BioFeedback Europe, you might easily pick up that idea, but let’s look at some facts that I extracted from BCIA’s own website:

BCIA began deciding who should be certified in neurofeedback 16 years ago, in 1998. Since then they have managed to certify just 735 brain trainers! That’s it! There are thousands of trainers operating in the world–at least 10 times the number who are certified.

For the first year, from 1997-1998 BCIA grandfathered a number of trainers who were experienced. Heck, even I was invited to become certified (I preferred not to). So how many of those 735 have actually gone through the certification process is unclear.

In the first years, BCIA was very restrictive about who could even apply. Since then they’ve broadened their requirements, but it hasn’t seemed to make a lot of difference in growth. In 2010, they made an additional effort to expand their base by going international. Even so, the number worldwide is just 735.

Of that group, 592 are in the United States–more than 40% in just 5 states. How’s it going with the international expansion after 4 years? There are 52 certificants–most in Holland–in the EU. 52. Canada has 44. Australia has 26. Those are places where there are active and organized neurofeedback communities and lots of trainers, but the total for the three largest areas outside the US just tops 100! In 4 years.

There are 3 groups which seem to be over-represented in BCIA:

a. First is academics (which may be why there are so many in the few large states). Academics like titles.

b. Second is people who want to expand their income by teaching or supervising BCIA applicants. You have to be BCIA certified to do that, and back in the early days I knew a number of people who tried that out. They were able to charge very high prices, but they didn’t make much money. More recently the field has been taken over by 11 firms which provide training courses–and, just by the way, sell their equipment and software in the process. One of those is the one offering a “certificate” course in Brasil for $995–that’s 2,400 Brazilian dollars, or 3-4 times the monthly minimum wage earnings for a 2 day course.

c. Third are people who just like to get a lot of certifications for whatever reason–I guess so no one can accuse them of now knowing what they are doing. The best example of this I ran into on the BCIA providers’ list was a masters-level provider with a thundering train of 10 certifications following the name: LPC-S, NCC, BCN, DTM, CLS, LMT, NCTM, CPT, ERYT, CGFI

What’s involved in passing the certification test? You have 3 hours to complete 100 multiple-choice questions–and get 65% of them right.

Probably the most important question is, what can you do with BCIA certification that you can’t do without it. The answer is simple: Nothing. Take a look at the amazing page on BCIA’s site titled Who Recognizes BCIA Certification?http://www.bcia.org/i4a/pages/index.cfm?pageid=3353

Let’s see: 1. BCIA says that as a result of their submission of a petition to the American Psychological Association, the APA agreed that “biofeedback” (not neurofeedback) is a proficiency appropriate for psychologists. It’s always a hard sell to convince the psychology board that a new modality should be theirs! No clinical licensure board of which I’m aware requires BCIA certification or even knows it exists. 2. The AAPB, BFE and ISNR membership organizations “recognize” that BCIA is the standard for certification. None require it. 3. Medicare, private insurance companies and the AMA all recognize that biofeedback is separate from other services and has its own codes (which most won’t pay for). Not sure what BCIA had to do with that. I am sure that BCIA certification doesn’t increase your chances of getting paid by insurors.

So there you go: in summary, over more than 15 years, even with companies beating the bushes to recruit and “prepare” people for BCIA certification, perhaps 1 in 10 providers around the world has bothered to get it. The only benefit they gain from having it is that they can put some initials after their names and perhaps get some part-time work mentoring and teaching for one of the for-profit companies who push it.

If you don’t believe me, visit their site.

Apologies to those who have heard me say this before:

Brain training is a technique; techniques are learned by doing them. The sooner a person begins working with brains (ideally with some guidance to help them get started with “what and where to train” in the beginning), the sooner they start seeing clients produce results, the more likely they are to recognize that it’s really the client who’s doing the work and the more comfortable they get with the process.

There’s always time to go back and fill in the “theory” blanks after you have some experiential hooks on which to hang the information. Or not. With a good system to help you make sense of what the client is presenting, with some humility in facing the client, with good coaching technique, amazing things can be achieved almost immediately and without spending a lot of money you have to get back from your clients.

The people I see who have spent the most time “studying” the brain and brain training are the ones who seem to make it all so complicated, so costly and who believe they must always do more instead of getting out of the way and letting the client’s brain change itself. I always told my trainers in Atlanta, “your boredom is not a good excuse for mucking around with someone else’s brain!” Yeah, it’s a lot more intellectually stimulating to get pages and pages of data and graphs and try to “figure out” how to intervene in the brain’s process, but recognize you are doing it for yourself–not necessarily for the client.

NTCB Certification

The NTCB certification does focus on presenting NF in a coaching vs. a treatment model–unlike BCIA–which is certainly one fairly proven way to avoid triggering any of the big dogs to get up and start barking at you.

NTCB has actually stood up and supported people who have been attacked in legal processes, professional people, even if they weren’t members of the organization, and has been very successful in getting positive results. To the best of my knowledge, BCIA has done nothing in any of these cases, since to do so would be to go against someone who has been very active in ISNR, even if the people being sued were members of BCIA.

NTCB has a very good and very inexpensive malpractice policy (and an informed consent form tested in court that goes with it) for its members, and the cost of getting the certification is a fraction of the cost of getting BCIA certification. I don’t know if getting NTCB certification makes you ineligible for BCIA–I would certainly hope not!–but that is something you could get fairly quickly and would provide you with a structure and support in the interim.

Education of Trainers

Lay trainers have developed their knowledge of NF slowly and with depth and humility just like the best pro trainers.

While I agree that there is a lot to know about depression or Asperger’s or RAD, for example, let me ask you a question: have you never had a mom or dad or client who came to you with an incredible amount of knowledge about these disorders? I’m stunned when I work with some of these families at how MUCH they know. They use the internet, the library, meetings with professionals and others dealing with the same problem to gain a tremendous depth of knowledge about the condition. In fact, in many cases, they know more about that specific condition than their clinically trained providers do. They teach me every time I meet with them to teach them. You, as a clinician, spent X years learning about all aspects of mental health. How much time did you spend specifically learning about RAD? About depression? Many of these people have spent that long and more delving into just that one area because of its personal importance to them in their lives.

One of the people on this list whose comments are most helpful and knowledgeable in the area of bipolar disorder is a mother who has spent years learning everything she could about the problem to help her son–after work with a clinician only went part way. A group with whom I have done training in California is made up entirely of parents who have RAD children. They have studied with the experts in that field, and they know as much or more than a great majority of the clinicians with whom they work about that one problem. Another group in Wisconsin has done the same. These groups and others in Virginia and elsewhere also band together to share their knowledge–not only of the clinical issues, but also of NF. They take courses from different teachers, they try various techniques and equipment options, and they share the information and support each other in ways that most clinicians either cannot or do not.

There is another whole field here that often gets lumped into the lay trainers: a special ed teacher or even a classroom teacher who does not have a clinical license but has a tremendous knowledge of kids and how they do and don’t learn, comes at NF from a different point of view. Do you honestly believe that those people are less qualified than a clinician? One of the 3 best trainers with whom I have ever worked was a classroom teacher who had an astonishing ability to relate to and motivate children and parents.

There is another side to this point. As good as you may be–as good as many clinicians may be–as well as they are able to spend the time to learn NF to the level of, say, a George Martin and integrate it with their clinical knowledge, the clinical degree and license does not guarantee that. I regularly run into folks who got into home training because they had spent months and thousands of dollars with someone who had a clinical degree and a license and a ticket in NF (maybe even stamped by BCIA) but who had a very shallow understanding of it. They applied the recipe(s) they had learned. When those did not work, it was the patient’s fault (resistant to treatment–after 100 ineffective sessions) or the family’s fault (not willing to come in often enough). They were more than comfortable with the well-trained understanding that they had good boundaries and that they could not help everyone. The parents and the clients don’t have that luxury.

Once again, I’m not saying that a lay trainer is a clinician in terms of breadth of knowledge of the mental health field, its history, its various theoretical orientations or all of its many diagnoses and syndromes. Most NF providers (professional and lay) end up working in a more restricted area anyway: they specialize in ADHD or developmental disorders or chronic pain or anxiety disorders. They become MORE expert in those areas. Why is Diane Stoler so good with traumatic brain injuries? Partly because she has HAD one herself. Her commitment was more than professional; it was personal as well. She lived with it every day and fought back from it and learned way more about it than the standard Ph.D. Exactly like many of the moms and dads and individuals themselves who get into lay training for a specific problem in their own lives.

My problem with the whole BCIA approach is that BCIA (founded and set up and defined by mental health clinicians ALONE) has tried to jerk the whole field around to its own single orientation. LOTS of people understand mental health and mental health problems. They live with them every day. Not all of them know the difference between cognitive behavioral therapy and psychodynamic psychotherapy. They may not understand the inner complexities of the diagnostic codings, and they may use different words for the concepts of resistance and boundary issues and transference, but they know what they are. Teachers, parents, coaches, engineers and a dozen others bring to working with people who want to change THEMSELVES an angle of knowledge and an area of understanding that the mental health clinician does NOT. If they are willing to spend the time and make the effort and go slowly with humility, accept help and advice and learn from experience and LISTEN to and respect their clients–as the very best clinically trained NF providers do–then I am of the opinion they should be allowed to practice and to demonstrate once again that there are a hundred roads to better health–not just one.

Lawsuits

I spoke with John Gilbert, since he has been at the center of the regulatory board and lawsuit (and threats to go to the FDA, etc.) activity, fighting the battle for the forces of truth, justice and the American way. In response to my question about client suits against NF practitioners, he trumped me. I’ve been saying that in 16 years in the field, I’ve never heard of one. John says in 32 years, he’s never heard of one! That’s as in zero, folks. So those who may be making their decisions with that bogeyman over their shoulders can (if they choose) take a nice deep breath and focus on relating to their clients instead of protecting themselves from them.

BTW, these numbers relate to the US, so what the climate might be like in Australia, Switzerland and other hotbeds of NF, I can’t say. However, since the US is personal injury heaven for lawyers relative to the rest of the world, I would assume the numbers would not be different in those places than here.

Vis-a-vis BCIA and its “pre-eminent” place in the field, John had some interesting facts used recently in a case in Michigan. There are 18 clinician NF providers in the state who are BCIA certified–112 who are not! Non-clinician providers (who of course can’t possibly be BCIA certified), 400 or more–and that’s not including those who are using “non-registered” devices like PETs and Pendants. In the cases where BCIA has testified against a provider, the provider has won EVERY ONE!

As we’ve discussed previously (and any of you who have hung out at all on the Biofeedback list can attest) there is a single source for all this litigation. World famous bibliographer and hypnotist extraordinaire Cory Hammond. Cory has wound up a group of about 18 other psychologists and gotten them fevered about the need to protect their turf from those of us beneath them. This group has filed or motivated the filing of almost all the actions of regulatory boards against individual NF providers. Most recently, however, the cases are being thrown out before they are even pursued, so the group may have decided that they followed a guy who promised to take them to the California coast and ended up in…Utah. The really ironic part now is that there is a group that will be seeking to certify only physicians and chiropractors, a group of whom want to deny NF privileges to psychologists!! Psychologists, they say, are practicing medicine without a license when they treat anxiety, depression or ADHD, all of which are MEDICAL problems based on CHEMICAL IMBALANCES!

Meanwhile, John Gilbert had some very good advice (from the trenches) to anyone wishing to practice: Use an Informed Consent form and carry liability insurance. He and a former FDA attorney drafted a simple informed consent that covers BF from the point of view of the FDA. It was my understanding in speaking with him that the form was available on the website for the Natural Therapies Certification Board (http://www.ntcb.org), but I can’t find it there. If anyone has a copy, please share it with the group.

The Biofeedback association provides, in the cost of membership ($150-265 a year) professional malpractice insurance, general liability–theft of equipment, etc.–and other benefits for its members. Most of us who want to work with clients can afford that.

BTW, for those on the list who feared what the dreaded Cory threatened–to take his case to the FDA and bring the wrath of federal regulators raining down upon the field–fear no more. He DID it. I said, he DID it. It’s done.

So let’s all take a deep breath and return our focus to the questions of how to get better results with our clients, checking out cool new pieces of equipment and software, tracking what’s happening in the media, running our businesses, etc.

No Licensure Requirement

There’s no requirement anywhere of which I’m aware that says you need to have a certain degree or a specific license (despite the best efforts of a few in the field) to do neurofeedback. If you do have a health provider license, you probably ought to make sure what the limits of practice might be that are defined by your licensure board, but otherwise you are pretty free. Some of the very best trainers I’ve ever seen or worked with don’t have degrees or licenses. They have committed themselves to becoming highly competent in the technology and they are natural coaches, who can motivate nearly anyone. They are very successful without insurance payments or marketing, because their clients get results and the word gets around. The key to practicing that way is simply to stay away from the “medical” jargon that has co-opted so much of our language. Anxiety used to be a useful English word; now it’s a diagnosis, and you have to be careful about using it. Don’t talk about attention deficit disorder; talk about helping people stay focused more effectively. Don’t talk about depressive disorders; talk about helping people increase their energy levels and positive view of the world. Don’t use the word cure. And don’t take credit for the work done by your clients. Your son’s improvements are the result of what HE has done–no matter how good his coach has been.

There are many who don’t have the experience in the medical field, haven’t been working with a great trainer, haven’t had the insurance plan to help pay for it–people who have started from scratch, learned from many different sources, worked at the process until they got good at it and have achieved remarkable results with problems that a psychologist would call autistic spectrum disorder, agoraphobia, OCD, ADHD, Generalized Anxiety Disorder, dysthymia and more. People who are motivated can do nearly anything with time and effort.

I’ve said a dozen times that I would be very happy to stand before any audience with Barry Sterman or Cory Hammond or anyone and argue whether individuals should be allowed to do neurofeedback, whether teachers should be allowed to do neurofeedback, whether coaches should be allowed to do neurofeedback, or whether there is any valid reason why only masters-level (or among some, Ph.D. level) (or among others, MD level) should be allowed to teach self-regulation. I’d be happy to argue purely on the merits or, even better, with case evidence. I think, for every case anyone could present showing a poorly-prepared “lay” trainer getting a bad result, I could present at least an equal number of poorly-prepared professionals getting bad results. And certainly I could present, just on the strength of this list, dozens or hundreds of cases of lay trainers who took the time to learn what they needed to know and worked carefully–with supervision from a local pro or over the internet or even just asking advice from time to time as issues arose–who got wonderful, life-changing results.

I find it ironic that Barry Sterman is still plumping for more “data”. If there is anyone in the field who should have seen the fallacy of that approach, it would be Barry, who produced some very well-done, high-quality research that was published 30 years ago showing the power of NF with seizure disorders. And yet today, if you were to poll neurologists–no, let’s just say, specialists in working with seizures–I dare say you would not find 1% who had ever heard of neurofeedback or Dr. Sterman, and probably not that many who would ever consider using or referring for neurofeedback. Same with the Peniston work, multiply replicated, with addictions–great research, well-designed, difficult to refute on any grounds–and completely ignored in the field of professionals who specialize in working with that population.

So for those innocents of you on the list, be warned. You are hanging out with rebels–generals and popes albeit, but rebels just the same. You can always choose to leave us and go to the room where King George and his ministers are muttering about that darned Washington guy and his rebels who are screwing up the world for everybody.

Part of the difficulty around this issue grows out of the aggressive expansion of the mental health field (via the DSM) into literally all areas of life. With physical problems it’s pretty tough to fudge much, since there are clearly-defined tests of physical function that indicate yes/no regarding, for example, diabetes. It’s not that easy for a manufacturer of medications to create a serious-sounding syndrome such as “social anxiety disorder” in the physical field. It has been estimated that, given the later versions of the DSM, perhaps the only thing that has grown faster than the national debt in the past 50 years, it might be impossible to find a man, woman or child who doesn’t have SOME mental health disorder.

If someone comes to me and says their mind is always racing, that they are afraid without knowing what they are afraid of, and that they always expect the worst, by what right–at least under western legal system–can someone tell me I can’t look for brain patterns consistent with that type of experience and provide her with the tools to change them herself. Of course if she goes to a physician or a therapist or some sort, she will most likely be diagnosed with some form of anxiety disorder, very likely with add-ons, and then only a licensed practitioner can work with her. The “disorders” that imbue and surround us all today and are such a blase part of our daily conversation (I heard a person at a party the other day tell a group of people, “I’m definitely bipolar!”) have been around forever. But the names and the professional apparatus that flourishes around them in western culture is relatively new and doing quite well, thank you.

So what one person’s attorney told him is that if you try to ride the “diagnosis/treatment” train, you have to have a ticket. But if you just want to help someone apply “the most powerful self-regulation technology since meditation” and you can stand just to deal with the person as an individual, without the interposition of a diagnosis and all that–and if that person values what you do to such an extent that they are willing to pay for your help and guidance (NOT “treatment”)–well, have at it.

Surely anyone who has been around much in the field is fully aware that just because a trainer has certification and licensure and education and continuing education in no way protects client against inept or even incompetent interventions. I just watched 5 board-certified neurologists kill my father-in-law and walk away without a scratch. NOT having the tickets but knowing the techniques and being a natural or developed trainer/coach doesn’t mitigate against excellent results. As George von Hilsheimer (a Ph.D. psychologist) has said/written a million times, professional credentialing is an economic activity–not a quality control function. There are fantastic trainers all over the world who are trained, licensed clinicians–and there are people with the same degrees and licensure who shouldn’t be training farm animals. Ditto for people who don’t have degrees or licenses.

Home Training

Brain-trainer is all about helping people who are interested and motivated to take on this challenge, especially when they can’t find a professional who can/well support them, to get the kind of results that make their investment in time, energy and money pay off. My answer to your question would be, 1. brain training is a “self-regulation technology”, so it can be and should be available to anyone who wishes to access it; 2. brain training neither requires nor (in my opinion) even BENEFITS from the “diagnostic” disorder-based approach that is taught to mental health clinicians. In fact many of the clinicians who have trained with me have been relieved to be able to work with their clients focusing on specific desired changes instead of focusing on figuring out the appropriate “name” for a problem and labeling their clients before they can help them. 3. brain training isn’t a simple technology that can be performed by just buying a machine and reading a book, but for those who are willing to make the commitment to learning what they are doing, it has the ability to give nearly anyone the ability to change or improve nearly any part of their lives–and often to make those changes in ways that will last with as much stability as the things they wanted to change lasted.

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